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Hernias of the Abdominal Wall: Inguinal Anatomy in the Male

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Hernias of the Abdominal Wall: Inguinal Anatomy in the Male Hernias of the Abdominal Wall: Inguinal Anatomy in the Male Bob Caruthers. CST. PhD The surgical repair of an inguinal hernia, although one of the in this discussion. The anterolateral group consists of two mus- most common of surgical procedures, presents a special chal- cle groups whose bodies are near the midline and whose fibers lenge: Groin anatomy remains one of the more difficult topics are oriented vertically in the standing human: the rectus abdo- to master for both the entry-level student and the first assistant. minis and the pyramidalis. The muscle bodies of the other This article reviews the relevant anatomy of the male groin. three groups are more lateral, have significantly larger aponeu- roses, and have obliquely oriented fibers. These three groups MAJOR FASClAL AND UGAMENTAL STRUCTURES contribute the major portion of the fascia1 and ligamental The abdominal wall contains muscle groups representing two structures in the groin area.',!.' broad areas: anterolateral and posterior (see Figure 1).The At the level of the inguinal canal, the layers of the abdomi- posterior muscles, the quadratus lumborum, do not concern us nal wall include skin, subcutaneous tissue (Camper's and aponeurosis (cut edge) Internal abdominal (cut and turned down) Lacunar (Gimbernatk) ligament Inguinal (Poupart k) 11ganenr Cremaster muscle (medial origin) Cremaster muscle [lateral origin) Falx inguinalis [conjoined tendon) Cremaster muscle and fascia Reflected inguinal ligament External spermatic fascia (cut) Figun, 1-Dissection of rhe anterior ahdominal wall. Rectus sheath (posterior layerl , Inferior epigastric vessels Deep inguinal ring , Transversalis fascia (cut away) '.,."" -- Rectus abdomlnls muscle \ Antenor-supenor 111acspme \ -. ,lliopsoas muscle Hesselbach'sl triangle inguinalis (conjoined) , Tesricular vessels and genital branch of genitofmoral Scarpa's fascia), external oblique fascia, from the upper six ribs course downward inguinal (Poupart's) ligament. This liga- cremasteric muscle fibers, spermatic obliquely and anteriorly to become the ment marks, in the groin, the separation cord structures, the transversus abdo- external oblique aponeurosis. The between the abdominal wall and the minis aponeurosis, the transversalis fas- aponeurotic fibers from each side inter- lower limb. Hernias that occur immedi- cia, preperitoneal tissues, and peri- lace with fibers from the opposite side ately above this ligament are considered toneum.'.'.' in the linea alba. Fibers of the external to be in the inguinal area, while hernias abdominal oblique fuse with fibers from existing below the ligament are called EXTERNAL ABDOMINAL OBUQUE the underlying internal abdominal femoral hernias (see Figures 2 and 3). MUSCLE oblique to form the sheath of the rectus The more medial of the rolled-under The external abdominal oblique muscle abdominis muscle.'.:,'.' fibers of the inguinal ligament flatten is the most superficial, thickest, and into a horizontal shelf. These fibers largest of the anterolateral muscle INGUINAL LIGAMENT attach to the os pubis, and this continu- groups. The muscle body is found later- In the groin area, a continuation of the ation of the inguinal ligament is called ally, having a strong, flat aponeurosis aponeurosis of the external abdominal the lacunar (Gimbernat's) ligament. occurring anteriorly. The external oblique stretches from the pubic tuber- The spermatic cord, which courses abdominal oblique muscle arises from cle to the anterior-superior iliac spine. through the inguinal canal, rests on the the lower outside border of the lower This extension is a rolled-under, inferior lacunar ligament until it turns to exit eight ribs. Fibers from the bottom two margin of the aponeurosis of the exter- through the superficial inguinal ring. ribs insert in the iliac crest, while fibers nal abdominal oblique and is called the Fibers that continue laterally along the 26 Fchruarv IYQB Thm Srr#loal T~ohnolo~lst anterior border of the superior ramus of In the upper abdomen, the intemal ic fascia and serves as the middle one of the pubis contribute to the pectineal abdominal oblique aponuerosis splits at the three covering layers oi the cord (Cooper's) ligament.'.'.' the linea sernilunaris, having an anterior and testis (see Figure 4).'.' and posterior sheath. In the lower quar- ter of the abdomen, the aponeurosis does INTERNAL ABDOMINAL OBLIQUE TRANSVERSUS ABDOMlNlS MUSCLE not split, but masses to the midline, MUSCLE The intemal abdominal oblique mus- anterior to the rectus abdominis muscle. The transversus abdominis muscle is the cle-as the middle one of the three flat The lower fibers arch over the spermatic innermost of the flat muscles of the abdominal muscles-is a thin, muscular cord and insert in the superior border of abdomen, having an extensive and var- sheet arising from the posterior layer of the pubis. These fibers join with similar ied origin in the cartilages of the six the thoracolumbar fascia, the anterior fibers from the transversalis tnuscle to lower ribs, the thoracolumbar fascia, the two-thirds of the iliac crest, the lateral form the falx inguinalis.'.',' iliac crest, and the inguinal ligament. two-thirds of the inguinal ligament, and The internal surface of the muscle is the iliacus fascia. Posterior fibers ascend lined by the tranversalis fascia.'.:.' CRENlASLlR MUSCLE AND vertically to the inferior borders of the FASCIA lower 3 or 4 ribs, while the other fibers The cremaster muscle originates from TRANSVERSAUS FASCIA spread fan-like in a forward and medial the inferior margin of the intemal The endoabdominal fascia forms a con- fashion. The ultimate insertion of these abdominal oblique muscle and forms tinuous lining of the abdominal cavity. fibers is the linea alba and the pubic part of the coverings of the cord and When this fascia lies deep to the trans- bone. testis: It underlies the external spermat- versus abdominis muscle. it is labeled Inferior epigastric vessels /covered by transversalis fascia) Linea alba External abdominal oblique muscle Transversalis fascia (site of / direct inguinal hernia) Aponeurosis of external Falx inguinalis (conjohed tendon) abdominal oblique muscle Trarlsveaus abdominis muscle Crenlaster muscle (medial origin) Cremaster muscle (lateral origin) lntercrural fibers Inguina! iPoupart's)ligament ~xternalspermatic fascia on Lacunar IGimbernark) ligament spermatic cord exiting Superficial inguinal ring Pectineal (Cooperk) ligament Reflected inguinal ligament / I ' Superficial inguinal ring Lateral crus Figure 3-Dissecrton of the ~nguinalregion (anrerior vtew). "transversalis fascia." When the canal is the deep inguinal ring found lacunar ligaments; the posterior wall- endoabdominal fascia is incact, no her- above the midpoint of the inguinal liga- sometimes called the "floorn-is formed nia exists; therefore, all hernias in the ment. The deep inguinal ring is not by the transversalis fascia and transver- groin represent a defect in the transver- truly "ring-like," but a finger-like diver- sus abdominis muscle. salis fascia. This fascia is attached to the ticulum of the transversalis fascia. The In the male, the contents of the iliac crest and descends upon the iliac canal is directed lateral to medial, deep inguinal canal include the vas deferens; fascia, serving as the superior fascia of to superficial, and cephalad to caudad, deferential artery and vein; testicular the pelvic diaphragm. The internal exiting at the superficial inguinal ring artery; lymphatics; autonomic nerves; spermatic fascia is the principle out- occurring above and lateral to the pubic the ilioinguinal nerve and genital por- pouching of the transversalis fascia; its tubercle. tion of the genitofemoral nerve; and the mouth is the deep inguinal ring.".' Whereas the superficial boundary of cremaster artery, which is a branch of the canal is formed by the external the inferior epigastric artery.'".'.' INGUINAL CANAL oblique aponeurosis, the most cephalad The inguinal canal is approximately wall is formed by the intemal oblique INFERIOR EPIGASTRIC VESSELS 4-cm long and obliquely oriented; it lies and tranversus muscles, along with The external iliac arteries supply blood 2 cm to 4 cm above and parallel to the aponeurotic fibers from each. The infe- to the legs, and the intemal iliac arteries inguinal ligament. Entrance to the rior wall is formed by the inguinal and supply the pelvis and perineum. The Ductus (vasl deferens covered by peritoneum Erternal iliac vessels covered by peritoneum Internal abdominal oblique muscle \ Ductus (vas) deferens External abdominal oblique muscle Inferior epigastric vessels Transversus abdominis muscle Cremasteric vessels Transversalis fascia Medial umbilical ligament (obliterated umbilical artery) Rectus abdominis mcacle Internal spermatic fascia Superficial inguinal ring 'Spermatic cord External spermatic fascia \ Femoral vessels enveloping spermatic cord Cremaster muscle and / \ Inguinal (Poupartk) ligament fascia on sperrnaric cord . / \:::-. I Figure 4-Spemur~c cord and ~ngulnalcanal 28 Febru~r\I"*S Tho Surgical Toohnoiogist External abdominal External abdominal Rectus shearh (anterior layer) Anterior-super~oriliac spine Superficial epigastric vessels Intercrural fibers Inguinal (Poupartk) ligament ring Figure &Femoral and inguinal regions (subcutaneous fascia has been removed). external iliac artery passes under the INGUlNAL HERNIAS The techniques of hernia repair are inguinal ligament at a point midway Several schemes are used to describe her- beyond the scope of this review,
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